Edit Reason Code: 5FPJP
Bill Type = 13X
CPT/HCPCS/Modifiers: G0277

Overview

The Medical Review Department of National Government Services will be performing service specific post-payment reviews for claims submitted to Medicare Part A. When a claim is randomly selected for review, the provider will receive an ADR letter. We must receive the medical records necessary to support the billed services within 45 days of the date of the ADR letter. Failure to submit the requested documentation in a timely manner may result in denial of the billed service. All documentation must be legible and authenticated by an acceptable handwritten or electronic signature. We will issue results upon completion of the post-payment review and offer education as needed.

Documentation Requirements

• • Legible physician orders and progress notes
  • History and physical
  • List of all diagnoses
  • Hyperbaric oxygen treatment records
  • Prior antibiotic therapy, wound care and surgical interventions
  • Current adjunctive treatment
  • X-ray findings and/or bone cultures
  • Medical documentation detailing prior course of treatment, which may include:
    • Physician order and progress notes
    • Lab and/or radiographic reports/test results
    • Wound therapy prior to HBO treatment
    • Pictures where necessary
  • Documentation as applicable to support medical necessity
  • If an ABN was issued, please include a copy of the signed and dated ABN of noncoverage given to the beneficiary.

Reference Documentation:

• • CMS IOM Publication 100-03, Medicare National Coverage Determinations (NCD) Manual, Chapter 1, Section 20.29 - Hyperbaric Oxygen Therapy

Posted 1/14/2021